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AERONAUTICAL DECISION MAKING

The Theory Behind

The Practice

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Definition of Aeronautical Decision Making (ADM)

“ADM is a systematic approach to the mental process used by all involved in aviation to consistently determine the best course of action in response to a given set of circumstances.”

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PRIMARY CAUSAL FACTORS OFAIRCRAFT ACCIDENTS

0 20 40 60 80

Misc

Airport/ATC

Weather

Maintenance

Airplane

Cockpit Crew

1987-98 1959-98

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PROBABLE CAUSE IN 80% OF ALL ACCIDENTS (NTSB)

0 10 20 30 40 50

UNKNOWN CAUSES

IMPROPER OPERATION OFEQUIPMENT

INFLIGHT JUDGMENT ORDECISION

PILOT TECHNIQUE

VISUAL PERCEPTIONMISJUDGMENT

UNPROFESSIONALATTITUDES 47%

19%

21%

5%

6%

4%

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PRACTICAL TEST STANDARDS REQUIREMENTS

“CRM is not a single TASK. CRM is a set of skill competencies which must be evident in all TASKS in this PTS as applied to the single pilot or the multicrew operation. CRM competencies, grouped into three clusters of observable behaviors are....”

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ADM SKILL MARKERS(“Observable Behaviors”)

COMMUNICATION SITUATION

AWARENESS WORKLOAD

MANAGEMENT PLANNING DECISION

MAKING

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CRM DEFINITION

“THE EFFECTIVE USE OF ALL AVAILABLE

RESOURCES”

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CREW... Pilot-in-Command Second-in-Command

Flight Instructor Aircraft Scheduler Weather Briefer Ramp Personnel Chief Instructor

Flight Attendant Check Airman/ Pilot

Examiner Flight Engineer Non-pilot Air Traffic Control Flight Service/Watch

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RESOURCES...

Time Information Workload Prioritization Strategies/Plans Scheduling

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MANAGEMENT...

Situation Assessment Risk Assessment Planning/Strategizing Prioritizing Tasks Allocating Responsibilities Problem Solving

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ENHANCED CREWMEMBER PERFORMANCE

C R E W M E M B E R N O N -T E C H N IC A L S K IL L S C R E W M E M B E R T E C H N IC A L S K IL L S

E N H A N C E D C R E W M E M B E R P E R F O R M A N C E

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ENHANCED CREWMEMBER PERFORMANCE

BriefingsInquiry/Advocacy/AssertionCrew Self-CritiqueCom m unications/DecisionsConflict Resolution

COM M UNICATIONSPROCESSES AND

DECISION M AKINGCLUSTER

Leadership/Follow ership/Concern for TasksInterpersonal Relationships/Group Clim ateAutom ation M anagem ent

TEAM BUILDINGAND M AINTENANCE

CLUSTER

Preparation/Planning/VigilanceW orkload Distributed/Distractions Avoided

W ORKLOAD M ANAGEM ENTAND SITUATIONAL

AW ARENESSCLUSTER

CR EW MEMBER NO N-T EC HNICAL SK ILLS

Visual Acquisition/Interpretation ofHazardsSystem ControlAircraft Control

M OTORACTIVIT IES

SKILLS

Em ergency/Abnorm alFlight M aneuversATC Com m unicationsSystem Operation

PROCEDURALACTIVIT IES

SKILLS

Com pany Policies/Law s/Rules/RegulationsATC/AirspaceW eatherAircraft Lim itations/Perform ance

INFORM ATION BASE/KNOW LEDGE

CR EW MEMBER T ECHN IC AL SK ILLS

ENHANCED CREW MEMBER PERFORMANCE

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ENHANCED CREWMEMBER PERFORMANCE

Visual Acquisition/Interpretation ofHazardsSystem ControlAircraft Control

M OT ORACT IV IT IES

SKILLS

Em ergency/Abnorm alFlight M aneuversAT C Com m unicationsSystem Operation

PROCEDURALACT IV IT IES

SKILLS

Com pany Polic ies/Law s/Rules/RegulationsAT C/AirspaceW eatherAircraft Lim itations/Perform ance

INFORM AT ION BASE/KNOW LEDG E

C R EW MEMB ER T EC H N IC AL SK ILLS

ENHANCED CREW MEMBER PERFORMANCE

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ADM Focus Non-Technical Skills

BriefingsInquiry/Advocacy/AssertionCrew Self-CritiqueCom m unications/DecisionsConflict Resolution

*COM M UNICAT IONSPROCESSES AND

*DECISION M AKINGCLUST ER

Leadership/Follow ership/Concern for TasksInterpersonal Relationships/Group Clim ateAutom ation M anagem ent

T EAM BUILDINGAND M AINT ENANCE

CLUST ER

Preparation/ *Planning/V igilanceW orkload Distributed/Distractions Avoided

*W ORKLOAD M ANAGEM ENTAND *S IT UATIONAL

AW ARENESSCLUST ER

C R EW MEMB ER N O N -T EC H N IC AL SK ILLS

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ADM SKILL MARKERS(“Observable Behaviors”)

COMMUNICATION SITUATION

AWARENESS WORKLOAD

MANAGEMENT PLANNING DECISION

MAKING

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COMMUNICATIONS

Two-way street Information transfer Clear, concise,

unambiguous Listening Repeating Clarification Understanding

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SITUATIONAL AWARENESS

THE ACCURATE PERCEPTION OR KNOWLEDGE A PILOT MAINTAINS TO THEIR OPERATIONAL ENVIRONMENT IN ORDER TO ANTICIPATE CONTINGENCIES AND TAKE THE NECESSARY ACTIONS.

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WORKLOAD MANAGEMENT

PRIORITIZE AND DELEGATE

SHARE AND COMMUNICATE

ACKNOWLEDGE PERSONAL LIMITS

ACTIVELY MONITOR

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PREPARATION, PLANNING, AND VIGILANCE

PREPARING FOR REQUIRED ACTIVITIES

PLANNING FOR ALL POSSIBILITIES MAINTAINING AWARENESS FOR

CHANGE

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Decision Making Process

1. Is there a decision to make?

2. Gather all available information.

3. Identify all possible alternatives.

4. Evaluate alternatives.

5. Choose an alternative (make a decision).

6. Act on decision.

7. Evaluate the results of the decision.

(if necessary, return to the beginning)

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THE EFFECTS OF STRESS AND FATIGUE

Human PerformanceError Management

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ADM MODELS AND PROGRAMS TODAY

PTS/CRM Pilot Judgment Training Manuals Personal Minimums FAA’s Model DECIDE Model Hazardous Attitudes Decision Making Process

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The Effects ofStress & Fatigue

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Stress & Fatigue

Not unique to the airline industry, or the transportation industry!

Our entire society is now driven by a 24/7 economy and lifestyle

It’s our individual responsibility to implement alertness management strategies

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Stress & Fatigue

What are causes of “chronic stress”?

How did the pilots surveyed deal with chronic stress?

What is your chronic stress level?

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Stress & Fatigue

Stress-Coping Strategies:

About half stated they were physically active to some degree

Remainder were less physically active, but involved in relaxation-type activities

All strategies provide a welcome diversion from stress.

What is your strategy?

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Human PerformanceStress & Fatigue

12 am 12 noon 12 am

3 - 5 am 3 - 5 pm

Performance level+_

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Stress & Fatigue

AA 1420 Little Rock, AR June 1, 1999

29

Stress & Fatigue

30

“You start with a bag full of luck and an empty bag of experience. The

trick is to fill the bag of experience before you empty the bag of luck.”

Human PerformanceAnd Error Management

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Human Errors Leading To Accidents...

How many errors need to occur before we have an accident?

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The “Roach Theory” of Errors

Errors are like roaches...

For every one you see...

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Errors are like roaches

There are different varieties…CommunicationsProceduralProficiencyIntentional Non-complianceOperational Decision

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Errors are like roaches

There are different species and sizesSlips - meant to do the right thing but

took incorrect actionLapses - omitted an itemMistakes - intention was incorrectViolations - (procedural non-

compliance) i.e. intentionally deviated from SOP or accepted procedure

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Error Enhancers

HurryFatigue/excessive stressLack of oxygen/water/foodDistractions/interruptions“First learned, best learned” Insufficient situation awarenessWorkload -too low or high

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More Error Enhancers

Language barriersCultural differencesInconsistencies in trainingInsufficient knowledge and skillsNon-standardized interfacesNight/weather

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Human Responses to Errors

Trap - error is detected and managed before it becomes consequential

Exacerbate - error is detected but the crew’s action or inaction becomes consequential

Fail to Respond - lack of a response to an error (undetected or ignored) that can either end up being inconsequential or consequential

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What Do We Do About Errors?

Prevent as many as possiblePractice detection and recoveryUnderstand and be vigilant for

potential “error enhancers”

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“Roach Prevention and Exterminators”

Planning Leadership Communications Decision Making Situation Awareness Workload

Management

Oh Noooo...

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Error Management and Roach Control

It is not possible to prevent all errors Error detection, prevention, and

recovery - error tolerance is the goal.The goal is met by improving human

performance in all facets of aviation.

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What about these?

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THE END

REMEMBER......MAKE ADM PART OF YOUR LESSON PLANS!

QUESTIONS????